Pilot of Home Visitation Services for Patients With a Diabetes Diagnosis

Status unconfirmed · Not applicable

Conditions studied: Diabetes

In brief

This pilot program will assess whether an enhanced PCMH model with more intensive management and intervention can improve chronic disease patient outcomes, improve healthcare delivery, and reduce healthcare costs. Participants in this program are current patients at Leland Medical Clinic and are either enrolled, or eligible to enroll, in Mississippi's Medicaid program. This pilot program will test the effectiveness of high-quality interventions comprising of: (1) an educational intervention focusing on chronic disease management and (2) home visits by a trained community outreach worker. This pilot program will evaluate both process measures and outcome measures. Examples of process measures include, but are not limited to, the number of patients enrolled in each intervention group, the number of educational classes attended by a unique patient, and the number of home visits a unique patient receives. Examples of outcomes measures include, but are not limited to, change in patient HbA1C levels, change in patient LDL/HDL levels, change in patient blood pressure (systolic and diastolic) levels, and a comparison of patient cost data (total expenditure, expenditures by other major categories like hospital, pharmacy, etc.) After baseline measurements, patient clinical values will be acquired every 3 months for the duration of their engagement. This pilot project has three specific goals: Goal 1: Improve healthcare delivery for chronic disease patients enrolled in Mississippi Medicaid. Goal 2: Improve clinical outcomes for chronic disease patients enrolled in Mississippi Medicaid. Goal 3: Reduce Mississippi Medicaid costs for chronic disease patients enrolled in this pilot program.

Key facts

Study ID

NCT03374098

Run by

Delta Health Alliance

People needed

150

Starts

2018-01-01

Expected to finish

2022-12-31

Last updated by the study team

2020-07-23

Who can join

Age: 18 and older. Sex: any. Healthy volunteers: not accepted.

You may qualify if…

• Leland Medical Clinic (LMC) patients
• Medicaid beneficiary or no insurance
• Active diabetes diagnosis
• Diagnosis of at least one other chronic condition (COPD, Hypertension, chronic kidney disease, CHF
• Baseline HbA1c 7.0 or above.

You may not qualify if…

• Patients with active psychoses will not be eligible.

Where it is running

• Leland Medical Clinic — Leland, Mississippi, United States

Full record on ClinicalTrials.gov

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